Challenges in the pathological assessment of cancer
(in the low & middle income countries) By
Dr. Lai-Meng Looi Founder President, College of Pathologists, Academy of Medicine Malaysia
Immediate Past-President, WASPaLM Distinguished Professor,
Department of Pathology, University of Malaya
UICC World Cancer Congress 2016 Paris 31 Oct - 3 Nov 2016 WHO session: Getting the diagnosis right: why pathology is needed, what is needed, and how to get there
CONTRIBUTION OF PATHOLOGY TO CANCER CARE
Screening Early detection of cancer and
premalignant conditions Diagnosis
Classification and subtyping Prognostic and predictive indicators
Monitoring Adequacy of treatment Recurrence Complications
Research Aetiology Cancer pathways Clinical trials
Cancer assessment is resource demanding
All branches of pathology Staff adequacy &
training Techniques
Basic to mutational analyses
Quality assurance Funding & infrastruture
The unequal world
From: Frenk J, Chen L, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Published online at www.thelancet.com on Nov 29, and in The Lancet Dec 4, 2010, vol 376; pp 1923–58); reproduced in expanded book, distributed by Harvard University Press.
Challenges for Pathology in Low and Middle income countries (LMIC) are
particularly acute Inadequate investment in
pathology Pathology competing poorly for
health budget • Inadequate infrastructure • Inadequate diagnostic repertoire • Inadequate training
Brain drain from poorer to richer communities Within countries Between countries
Health is a fundamental right! Pathology services has pivotal role in health & disease How do LMIC catch up with the rest of the world?
Development of Pathology Laboratory Services in Malaysia:
A story of capacity building & advocacy
Training
Accreditation Legislation
Professional engagement International collaboration
Ethnic distribution 50.1% Malay 22.6% Chinese 11.8%Indigenous 6.7% Indian 8.8% other
Malaysia
Independence from the United Kingdom • Federation of Malaya - 31 August 1957 • Malaysia (Peninsular Malaya, Sabah, Sarawak, Singapore) -16 September 1963 • Expulsion of Singapore -9 August 1965 Population: 30 million
GDP (2014) in USD • Total $338.10 billion • Per capita $7304.14
Training of pathologists Upon independence (1957)
IMR lost expatriate officers (75% of staff) Rapid growth of medical and laboratory services Shortage of pathologists
Immediate post-independence era Training via DCP (London) or MRCPath (UK) Expensive; unable to keep up with country’s needs Local Master of Pathology (MPath) programmes UM (1973), UKM (1988), USM (1992); UPM, UiTM
Model against international practices 1987- MPath conversion from 2-yr to 4-year fulltime programmes Train mono-discipline pathologists at FRCPath level Mandatory research project
Pivotal role of Universities & international connections
Human Resource Development 1994: 120 medically-qualified pathologists; 10% private
practice 1994: Landmark workshop between MOH and Universities Acknowledged that production of pathologists not meeting national needs. Strategy: Utilize accredited Departments of Pathology of MOH hospitals as
training ground Recruit MOH pathologists into training Faculty Step-up production of pathologists
2007: 300 medically-qualified pathologists; 150 trainees Population >25 million; Pathologists: Population ratio 1:90,000 Target for 2010 : 1: 75,000
Today: >500 medically-qualified pathologists Population 30 million; Pathologists: Population ratio 1:60,000
Training for other LMICs Sudan, Yemen, Iran, Sri Lanka, Myanmar.
A rapidly expanding market!
2006: 240 million pathology laboratory tests 46% in MOH, 10% in University hospitals,
44% in private laboratories Private sector: > 200 labs; > 40 pathologists
Concerns over Quality
Department of Standards Malaysia, MOSTI
Established through Standards of Malaysia Act, 1996 Accreditation functions
Accreditation services to certification bodies & testing organizations Identify & develop accreditation schemes needed by country Liaison with similar overseas bodies Develop mutual recognition arrangements to enhance
Malaysian competitiveness Signatory to APLAC and ILAC
Accreditation of certification bodies (ACB) Skim Akreditasi Makmal Malaysia (SAMM)
Good track record since 1990 Expanded to Medical testing laboratories in 2004
College of Pathologists Academy of Medicine Malaysia
supports Accreditation Sole Professional body of medically qualified
specialist pathologists in Malaysia (since 1975) Objectives To promote and maintain the highest moral, ethical
and professional standards in pathology practice • Quality & appropriate practices • Scientific advances & Research • Continuing professional development • Postgraduate education & training • Public education
Development of MS/ISO 15189
Memorandum of Understanding between DSM and College of Pathologists, Academy of Medicine Malaysia in late 2002
Steps in development of MS/ISO 15189
Public forum in December 2003 Need for accreditation of Medical
Testing Laboratories Rationale for adoption of ISO 15189
Training of 20 lead assessors & 60 technical assessors throughout 2004 Collaboration with CPath Training by IANZ Writing of specific documents
Launch of MS/ISO 15189 in December 2004
Development of 6 Professional Practice Guidelines by CPath by April 2005
Retention of Pathology Records and Materials Minimum qualification, training and experience of
professional personnel working in a pathology laboratory
Laboratory construction and design Maintenance and operation of equipment in a
pathology laboratory Safe laboratory practice Sample management
Advocacy for legislative
regulation of pathology
laboratories
1983: Memorandum to MOH by Malaysian Society of Pathologists - need for legislative control of laboratories
Annual dialogues with Minister of Health Consultations with relevant professional
bodies & stakeholders (1997 & 2000) Malaysian Association of Private Medical Laboratories Malaysian Institute of Medical Laboratory Scientists
(MIMLS) Malaysian Society of Clinical Biochemists Malaysian Medical Association (MMA) Federation of Private Med Practitioners Association Msia Others
Issues raised (2001-2006) MMA wants Labs to conform to fee schedule Discrepancies in test results from different labs Controversies over “Walk-ins” Abuse of screening tests; test vouchers; etc Support for Pathology Act: “Why the delay?”
Legislation: The Pathology Laboratory Act 2007
What the Pathology Act sought to ensure Lab is accountable to the public Lab meets required standards of practice Participate in QA programmes Run by qualified staff Comply with safety requirements Subject to continuous audit
Requirements are similar to Accreditation, but backed by legislation
Landmark Developments National Accreditation Standard for
Medical Testing Laboratories (MS ISO 15189) - 2004
National guidelines for Good Laboratory Practice – CPath 2005
Pathology Act 2007 QA programmes - MOH, LABQAS (CPath-
MIMLS), MEQAS (CPath-AMM) Malaysian Journal of Pathology Encourage research; now 38th year and ISI
What is WASPaLM? A global network of
physician-led Pathology Societies 1947:Founded in Paris
Global geographical distribution 45 Societies in 34 countries North America (4) South America (7) Europe (19) Asia (12) Australasia (1) Africa (2)
Elected Bureau President Vice-President Secretary-Treasurer Regional Directors
• North America • Latin America • Europe • Asia • Australasia • Africa
4 Directors-at-large
Objectives of WASPaLM
Mission To promote health throughout the world by promoting
the teaching and practice of all aspects of Pathology/Laboratory Medicine
Goals To promote education, research and international quality
standards, through WASPaLM Committees & Secretariats, and the World Pathology Foundation
To promote high quality, cost effective medical laboratory services To encourage the formation of, and cooperation between,
societies of Pathology and Laboratory Medicine throughout the world
To foster cooperation between WASPaLM and other international health organisations
What WASPaLM does Voice of Pathology World Health
Organisation International Health
Terminology Standards Development Organisation (IHTSDO)
ISO/TC 212 Others through
constituent members e.g. International Collaboration on Cancer Reporting
Collaborations with related professional bodies International Federation of
Clinical Chemistry & Laboratory Medicine (IFCC)
Asia-Pacific Federation of Clinical Biochemistry (APFCB)
Labs -are-Vital
What WASPaLM
does Capacity-Building Education for countries-in-need
• Seminars and workshops in South-East Asia, Sri Lanka, India, Middle-East and Africa
• WASPaLM provides seed grants • Expertise contribution from strong/donor Societies • Ground support from recipient/hosting Societies
Educational Workshops/Symposia in Countries-in-need
2003: Vellore, India 2004: Sri Lanka 2005: New Delhi, India 2006: Bangalore, India 2007: Pune, India 2008: Penang, Malaysia 2009: Muscat, Oman 2010: Chandigarh, India 2011: New Delhi, India 2012: Sri Lanka, Malaysia 2014: Khartoum, Sudan 2015: Yangon, Myanmar
Intensive workshops & seminars to enhance expertise Areas of need decided with
recipient countries Attendance often >200
participants Draws participants from
neighboring countries
WASPaLM Education and Visiting Lecturer Programme (2012-)
Funds for visiting faculty travel to educational programmes organised through WASPaLM Constituent Societies
Seminars/ Symposia Luthuania, Cyprus, Turkey,
Malaysia, Riyadh, Indonesia, Sudan, Myanmar
World Pathology Foundation Gordon Signy Fellowships (1975-) Enable young pathologists from
countries with limited resources to visit centres of renowned excellence to acquire special skills and expertise
50 beneficiaries from 22 countries esp. LMIC: Fiji, Nigeria, India, Malaysia, Jordon, Hungary, Hong Kong, Yugoslavia, PR China, Tanzania, Thailand, Brazil, Iran, Zimbabwe, Turkey, Bulgaria, Peru, Lithuania, Sri Lanka, Mongolia, Ethiopia, Cameroon, Nepal.
“Mediator of Pathology Knowledge between those who generate it and those who need it” Robby Bacchus, WPF President
The 29th World Congress of World Association of Societies of Pathology and Laboratory Medicine
The 64th Annual Meeting of Japanese Society of Laboratory Medicine
Contribution to Medical Innovation of the Next-Generation
President
Masami Murakami, MD, PhD Department of Clinical Laboratory Medicine Gunma University Graduate School of Medicine Maebashi, Japan
Date
Venue
November 14 (Tues) - 19 (Sun), 2017 Kyoto International Conference Center, Kyoto, Japan
Thank you!